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Retiree Benefits Enrollment Form 2021-22
Click to view (pdf or doc)
Plan year July 1, 2021 through June 30, 2022 Retirees should use this form to enroll in health, dental and vision plans.
Revision date: 04/23/2021
Submit paper form to Benefits Office, 112 Scovell Hall, Lexington KY 40506-0064
Email form back to email@example.com